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Palmar fibromatosis (Dupuytren's contracture)

 
Palmar fibromatosis (Dupuytren’s contracture) is a condition in which tissue in the palm of the hand covering the finger tendons thickens and scars. The affected tissue, called the palmar fascia, becomes tight and shortened, contracting the fingers inwards toward the palm.
 
The development of the condition usually occurs quite slowly over many months, or even years, though in rare cases it can develop suddenly.  It can affect any of the fingers, but it most commonly affects the ring finger (fourth digit) and little finger (fifth digit). It can occur in only one hand or in both hands at the same time. 

Causes

Palmar fibromatosis is a relatively common condition but its cause is not fully understood.  In most cases it does not occur until after the age of 50 years and it is more common in men than women.
 

Palmar fibromatosis runs in families, and is more common in people of Northern European decent, so it is thought that genetics can play a part in the development of the condition. Other factors that may increase the risk of developing palmar fibromatosis include: 

  • Diabetes 
  • Smoking
  • Alcohol abuse - particularly where liver disease is also present
  • Occupations exposed to repetitive vibration.

Signs and symptoms

Often the first sign of the condition is a painless lump in the palm of the hand near the base of the fingers. This may be followed by a feeling of tightness and/or tenderness in the fingers.  As the condition progresses it is difficult to fully straighten the fingers and there may be dimpling and puckering of the skin over the area. Eventually contracture of the fingers may become so severe that they cannot be used.
 

Palmar 1

  
The condition is not painful in itself.  However, some pain may be experienced if the fingers are forcibly straightened.  In some cases the muscles in the hand may become weakened and wasted through not being able to be properly used. 
 
As the condition progresses, palmar fibromatosis can limit the ability to perform certain tasks such as typing and grasping objects, and the affected hand can get caught when trying to get into narrow places such as a pocket.

Diagnosis

Often the characteristic symptoms of the condition are enough for the doctor to suspect palmar fibromatosis. A formal diagnosis of the condition is made based on assessment of the medical history and a physical examination, and by ruling out other conditions that may be causing the symptoms. 

Treatment

Treatment of palmar fibromatosis will depend on the severity of the condition. If the condition is not severe and is not greatly inconveniencing, treatment may not be required. The doctor may recommend monitoring the condition so that treatment can be prescribed when necessary.
 
Gentle stretching exercises and the application of heat and/or ultrasound may be recommended in the early stages. A referral to a physiotherapist may be made for this.  If there is pain or inflammation in the area, corticosteroid injections directly into the affected area may be recommended.
 
Surgery
Once palmar fibromatosis progresses to a point where the condition is limiting or disabling, surgery is usually recommended.  The surgical procedure is known as a “fasciectomy” and involves making an incision in the skin of the palm above the affected area - often in a zig-zag pattern. The scar tissue is exposed and removed, releasing the tendons and allowing the fingers to flex and contract normally.  This is a relatively simple and highly successful procedure and is usually performed under a local anaesthetic or nerve block that numbs the arm.
 
Surgery is followed by a period of recovery and rehabilitation. The time required for this will vary between individuals. It may be necessary to wear a bandage, cast or splint for a short time after surgery.  Physiotherapy and an exercise programme (physical therapy) will be recommended to help restore finger mobility and function.
 
There is a possibility that the condition can recur after it has been surgically corrected. This tends to be related to the age of onset - the earlier the condition develops in life the more likely it is to recur. 
 
Needle aponeurotomy
Also known as needle fasiotomy or "needling", this procedure involves inserting a needle through the skin to puncture and break the cord of tissue that is causing the finger to bend.  This is done under a local anaesthetic and is only suitable for some types of palmar fibromatosis.  Needle aponeurotomy can be performed on serveral fingers at the same time and minimal physical therapy is required afterwards.
 
Collagenase injection
Collagenase is an enzyme that is injected into the cord of tissue responsible for the bending finger to soften and weaken it so that the finger can be manipulated and straightened.  Recovery is quicker than with surgery and may not require physical therapy. However, not all cases of palmar fibromatosis can be treated this way.  Collagenase is not an established treatment in New Zealand.

References

Healthinfo clinical advisors (2017). How is Dupuytren treated? (Pamphlet). Christchurch: South Canterbury District Health Board. https://www.healthinfo.org.nz/patientinfo/109180.pdf
O’Toole, M.T. (Ed.) (2013). Dupuytren’s contracture. Mosby’s Dictionary of Medicine, Nursing & Health Professions (9th ed.). St Louis, MI: Elsevier Mosby.
Mathew, S.D. (2016). Dupuytren contracture (Web page). Medscape Drugs and Diseases. New York, NY: WebMD LLC. https://emedicine.medscape.com/article/329414-overview [Accessed: 18/10/17]
Mayo Clinic (2016). Dupuytren’s contracture (Web Page). Rochester, NY: Mayo Foundation for Medical Education and Research. http://www.mayoclinic.org/diseases-conditions/dupuytrens-contracture/basics/definition/CON-20024378 [Accessed: 10/07/16]
 
Last Reviewed – October 2017
 

 

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